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' <br /> San Joaquin County Environmental Health Department <br /> DATE ,S OSMASTER FILE RECORD INFORMATION "MFR" GREEN FORM <br /> 5l1ADF...s,a sHn- wnesn' OWNERID# CASE# UNIT IV <br /> OWNER FILE <br /> COMPLETE 7NEFOLLOWING INFORMATION; / CRECKIF OWNER CuARenrcroNTnE wrrN END <br /> ' PRDPEmYow NAME E R S 1 1 1-7y @ lA PHONE �O9 O O7eF2 <br /> First M! Lasf <br /> BUSINESS NAME SDE SEC/TNI ID# <br /> ' Owner Home Address E3;L7 Ra,^ F/owe#- r V DRIVER'SLTEENSE# <br /> °h' L/✓eo-ndbre Zee/ STATE CA '?ysS-o <br /> Owner Mailing Address SQIt�lC atf 0�1TC od✓tSS <br /> Mailing Address City State Tip <br /> ' ccMPORATWN❑ 114031DAIAI PAROFRSHm❑ Fm Afabi OTtER❑ <br /> FACILITY FILE <br /> FACEUTYIDAs V CROs REF ID as ACCOUNTID# Inst <br /> IWWLEM L <br /> u this a NEW Business LOCATION not previously regulated by the ENVIRONMENTAL HEALTH DEPARTMENT? Yes ❑ No ❑ <br /> Is this an D¢STiNG Business LOEATION but a NEW TYPE of regulated Business? YES ❑ No ❑ <br /> BuSRSss/FACBrrr/SITE NAME <br /> lyes W. brant Gaq� Qoa4 suaE# Suavest;PHOW <br /> `rre Tr ct c STATE CA 2" ?0 9/ <br /> eawD OF sUaift at DISTRICT LOCATIONCODE KEY1 KEY2 <br /> Mailing Address ifDIAFERENTfrum FadlityAddresr Attention:or Care Of(optional) <br /> S -7 ower �rVQ <br /> Mailing Address City Lrve< AAclet STATE CA ZV <br /> ' SIC CADS "He COMMEM: <br /> THIRD PARTY BILLING INFO: Completed Billing Party is different from Property Owner or Facility Operator identi/ied above. <br /> ' RUSUESSNAME 1 Attention:or Care Of (optional) <br /> wallAce � k'441 ( V A5soce4ates r <br /> Malting Address(3 qlo West kA^AeAe-r L"o"-Ae- Sttl e r PHONE 209 Z3y --77ZZ <br /> Cm STO c Kf PA STATE C/f W 9SL(/Q <br /> e=,� XAefor fees and charges OWNER FACILITYIBUSINESS THIRD PARTY BILLING <br /> : 1,the undersigned Applicant,certify that lam the Owner,Operalnr,or Aurhnrized Agent of this Dusinesa,and 1 acknowledge that all PERAIII FE£$ <br /> PENALRE.S,ENFORCENEMCHARGES And/or 110URLYCIIARGEI'assuciated with this operation will he billed tome strive address identified above as the ArY'(11M'AnnREes'for this site. I also certify that <br /> all mformatlan provided Oa this application Is true and forrMtl and that all regulated aetiviltes will be performed In accordance with all applicable SAN JOAQUIN COUNTY Ordinance Cadez snd%or <br /> Slondards end STATE end/or FEDERAL Laws and Regulations. As the undersigned owner,operator,or agent of the property located at the above facilitylsite address,I hereby authorize the release of <br /> any and all results and environmental assessment information to SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is available and at the same time it is <br /> provided to mear my representative. PLEASE PONT <br /> APPLICANT NAME Fr-,P-dW• G f Lls SIGNATURE <br /> TIRE DRNEWS C <br /> ENSE#fy-' ec- (PHOTOCOPY RED1 <br /> Apposed By Date Accoundno Omen Processing Completed By Dabs <br /> ' 29-02-002 April 25,2003 <br />